Improved Maternal and Infant Outcomes with Serial, Self-Reported Early Prenatal Substance Use Screening.

INTRODUCTION: Most screening tools identifying women with substance use are not validated, used once in pregnancy, and are not reflective of continued substance use. We hypothesized that serial early prenatal substance screening leads to decreased substance use by the end of pregnancy and improved outcomes. METHODS: This is a retrospective cohort study of mothers and their infants between 1/2015 and 12/2017. A self-reported substance screening tool was administered on the first prenatal visit and subsequent visits until delivery. For analysis, mothers were divided into three groups based on the trimester of their first screen and adjusted for demographics and risk factors. RESULTS: Early first trimester screening resulted in 52% of mothers having ≥ 3 screens throughout pregnancy vs. 6% of mothers with late third trimester screens (p < 0.001). Compared to third trimester screening, there was a five-fold decrease of any substance use at second trimester, a seven-fold decrease at first trimester, and a nine-fold decrease for marijuana at first trimester. Compared to third trimester screening, there was a significant five-fold increase of negative maternal urine drug screen, 3 ½ -fold increase in well newborn diagnosis, and a five-fold increase of no infant morphine treatment at first trimester. DISCUSSION: We identified improved maternal and infant outcomes with serial early prenatal substance use screening. Early maternal substance use identification is crucial for immediate referral for prevention and treatment, and for social and community services. Further research is needed on universal serial early prenatal screenings.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Antibodies in Neonatal Cord Blood After Vaccination in Pregnancy.

BACKGROUND: Studies evaluating the safety and efficacy of currently available vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) do not include pregnant participants. No data are available to counsel on vaccine safety and potential for neonatal passive immunity. CASE: A 34-year-old multigravid patient working in health care received the Pfizer-BioNTech (BNT162b2) mRNA vaccine for SARS-CoV-2 in the third trimester of pregnancy. Uncomplicated spontaneous vaginal delivery of a female neonate with Apgar scores of 9 and 9 occurred at term. The patient's blood as well as neonatal cord blood were evaluated for SARS-CoV-2-specific antibodies. Both the patient and the neonate were positive for antibodies at a titer of 1:25,600. CONCLUSION: In this case, passage of transplacental antibodies for SARS-CoV-2 was shown after vaccination in the third trimester of pregnancy.

Hospital care for opioid use disorder in pregnancy: Challenges and opportunities identified from a Minnesota survey.

OBJECTIVES: The prevalence of opioid use disorder continues to rise in the United States, with a simultaneous increase in the diagnosis of both opioid use disorder during pregnancy and neonatal opioid withdrawal syndrome. Despite these increases in pregnancy-related care, little is known about hospital policy and policy implementation related to opioid use disorder in pregnancy. In addition, it is unknown whether policies might differ in rural or urban hospitals. To better examine these issues, Minnesota hospitals were surveyed regarding the existence and implementation of policies related to opioid use disorder in pregnancy and whether any policy implementation challenges had been identified. METHODS: From August to December 2017, the research team contacted all Minnesota hospitals that offered obstetric services (n = 82) to survey challenges to implementing policies for opioid use disorder during pregnancy, among other questions. Fifty-nine hospitals had respondents (primarily obstetric department supervisors) who provided information about policy implementation challenges for a 72% response rate. Qualitative responses were analyzed using qualitative description and according to hospital location: metropolitan (urban), micropolitan (rural), or non-core (rural). RESULTS: Ninety-one percent of respondents said that they had pregnancies affected by opioid use disorder at their hospital within the last year. Four major challenges to policy implementation were identified in qualitative responses: (1) provider consensus, (2) patient response to policy, (3) lack of resources, and (4) low frequency of occurrence. All four challenges were more frequently identified by respondents at rural hospitals compared to urban hospitals. CONCLUSION: This study identified challenges in standardizing hospital care for pregnancies affected by opioid use disorder, and these challenges were identified more frequently in rural locations. These non-urban hospitals may require increased state and federal support and funding.

Opioid prescribing trends in postpartum women: a multicenter study.

BACKGROUND: The postpartum period can be a particularly vulnerable time for exposure to opioid medications, and there are currently no consensus guidelines for physicians to follow regarding opioid prescribing during this period. OBJECTIVE: The purpose of this study was to evaluate inter- and intrahospital variability in opioid prescribing patterns in postpartum women and better understand the role of clinical variables in prescribing. STUDY DESIGN: Data were extracted from electronic medical records on 4248 patients who delivered at 6 hospitals across the United States from January 2016 through March 2016. The primary outcome of the study was postpartum opioid prescription at the time of hospital discharge. Age, parity, route of delivery, and hospital were analyzed individually and with multivariate analyses to minimize confounding factors. Statistical methods included χ2 to analyze frequency of opioid prescription by hospital, parity, tobacco use, delivery method, and laceration type. An analysis of variance was used to analyze morphine equivalent dose by hospital. RESULTS: The percentage of women prescribed postpartum opioids varied significantly by hospital, ranging from 27.6% to 70.9% (P <0.001). Oxycodone-acetaminophen was the most commonly prescribed medication (50.3%) with each hospital having its preferred opioid type. Median number of tablets prescribed ranged from 20 to 40 (P < .0001). Primiparous women were more likely to receive opioids than multiparous women when broken down by a parity of 1, 2, 3, 4, and ≥5 (52.8%, 48.0%, 47.6%, 40.1%, and 45.8%, respectively, P = .0005). Among women who had vaginal deliveries, opioid prescription rates were higher in women who experienced either a second-degree laceration (35.5%, P = .0002) or a third-/fourth-degree laceration (59.3%, P < .001). CONCLUSION: Postpartum opioid prescription rates vary widely among hospitals, but providers within the same hospital tend to follow similar prescribing trends. The variation in prescribing found in our study illustrates the need for clear consensus guidelines for postpartum pain management.

Pregnancy and Naltrexone Pharmacotherapy.

A 25-year-old woman, gravida 3 para 2 at 12 weeks of gestation, with two prior cesarean deliveries, presents for prenatal care. She is in treatment for opioid use disorder on extended-release naltrexone injection, with a history of opioid overdose, relapse, and poor treatment adherence on methadone and buprenorphine. She asks, "Is it safe for my baby if I continue on this medication? How will you manage my postoperative pain?"

Opioid Use Disorders and Pregnancy.

Opioid use disorder presents an increased risk of complications in pregnancy, particularly when untreated. To optimize outcomes, medication-assisted treatment using methadone or buprenorphine as a part of a comprehensive care model is recommended. Neonatal abstinence syndrome and poor fetal growth remain significant complications of this disorder despite maternal treatment.

Maternal opioid dose is associated with neonatal abstinence syndrome in children born to women with sickle cell disease.

The objective of this study was to test the hypothesis that higher daily opioid dose is associated with the presence and severity of neonatal abstinence syndrome (NAS) in pregnant women with sickle cell disease (SCD). This was a retrospective study of pregnant women with SCD who required opioids. NAS was evaluated using the Finnegan scoring system and classified as none, mild, and severe. Severe NAS was defined as a Finnegan score ≥ 8 on 3 consecutive tests. Thirty-four pregnancies were examined in 30 women with SCD. Higher daily morphine dose was associated with a higher percentage of days in the hospital during pregnancy (P < 0.001). Hospital days contributed disproportionately to daily morphine dose as larger amounts of opioids were administered in the hospital compared to home (P = 0.002). Median maternal oral morphine dose was 416 mg for infants with severe NAS compared with 139 mg for those with mild NAS (P = 0.04). For infants with no NAS, median maternal morphine was 4 mg, significantly less than those with mild NAS (P < 0.001). Infants born to women who used on average >200 mg/day of oral morphine equivalent in the last month of pregnancy had a 13-fold increased risk of severe NAS compared with those who used <200 mg/day. These data demonstrate that higher median daily opioid dose is associated with progressively more severe NAS in pregnant women with SCD. Strategies to decrease pain and avoid hospitalizations are needed to reduce opioid use and NAS.

Sildenafil increases uterine blood flow in nonpregnant nulliparous women.

This study investigated the effect of sildenafil on uterine volumetric blood flow (UVF) and vascular impedance in nonpregnant, nulliparous women. Fifteen women were randomized in a double-blind fashion to receive either placebo or sildenafil (25 or 100 mg) during the luteal phase of the menstrual cycle. Color Doppler ultrasound of both uterine arteries was performed at baseline and at 1 and 3 hours postdosing to calculate resistance index (RI) and UVF. Those who received sildenafil significantly increased UVF and decreased RI over the 3-hour monitoring period. When UVF responses to sildenafil were examined as a function of baseline UVF, a significant increase in UVF was observed in only those participants with higher baseline UVF. Overall, women in the luteal phase demonstrated a significant increase in UVF in response to sildenafil. However, this increase appears to be directly associated with basal UVF.